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Psychiatric and psycho-social characteristics of suicide completers.

A recently published article examines the psychiatric and psycho-social characteristicsof people dying by suicide in the West of Ireland.1 As background, the authors note national statistics showing that between 2001 and 2013 there were approximately 500 deaths by suicide in Ireland, and that the incidence of suicide among Irish males was four times greater than among females. The authors also cite a WHO report showing that, while the rate of death by suicide in Ireland is the eighth lowest in Europe compared to 26 other countries, in the 15–24-year-old age group Ireland ranks fourth highest.

The authors list the large number of potential risk factors for death by suicide that have been recognised in the literature. Psychological autopsy studies have shown that 60% to 90% of individuals have suffered with a psychiatric illness before their death by suicide. Alcohol abuse and/or psycho-active substances as well as borderline personality disorder have been highlighted as risk factors. There is an increased risk if the person has experienced adverse childhood trauma such as a violent episode or sexual abuse, although confounding factors need to be considered. Previous contact with mental health services and prior suicide attempts have also been found to be significant risk factors: the first two weeks following discharge are the period when individuals are at most risk. Other epidemiological studies show that genetic factors, independent of mental illness, are another important risk factors to consider for suicide.

Previous episodes of deliberate self-harm are also a major risk factor for death by suicide: studies assessing self-harm have shown that 52% to 63% of individuals who have had one or more episodes of self-harm have later died by suicide. Death by hanging has been shown to be the most common method of suicide. Gender differences have also been found, with hanging and death by firearm more prevalent among men and self-poisoning more prevalent among women.

Aim and objectives

The aim of the study was to identify the demographic, psycho-social and clinical characteristics of individuals known to mental health services who died from probable suicide in the West of Ireland (HSE West region including West Galway, East Galway and Roscommon). The study examined each individual’s method of death and toxicology findings at time of death. It also characterised previous deliberate self-harm and suicide attempts and mental health diagnoses.

Method

All post-mortems carried out in University College Galway (UCHG) between January 2006 and May 2012 (n=1,991) were reviewed. The post-mortem reports, which included detailed reports from the consultant pathologist, witness statements, garda summaries and toxicology reports, were assessed against the study inclusion criteria, and 181 individuals were determined to have died by probable suicide. Of these, 57 individuals were found to have been known to the mental health services and these individuals formed the cohort for the study.

Results

There were more males to females in the study cohort (ratio 4:1), the majority were unemployed (58%) and the mean age was 47 years. The highest proportion was aged between 34 and 55 years (Table 1).

Many individuals had a history of identifiable risk factors:

A recurrent depressive disorder or a major depressive episode was the most common psychiatric diagnosis (44%), followed by alcohol dependence syndrome (35%).

Eight individuals with depression (32%) were alcohol dependent or made harmful use of alcohol.

23% suffered from chronic pain, with six of these individuals reporting a chronic medical illness.

44% had a history of adverse childhood experiences.

Those with chronic pain (23%) had higher rates of childhood trauma compared to those without a history.

Attendance at mental health services was as follows:

33 individuals (58%) were still registered (actively attending) mental health services at the time of their death;

20 individuals (35%) had been in contact with the mental health service in the month before their death; and

40 individuals (70%) had been previously admitted to a psychiatric unit, of whom eight had been discharged within a month of their death.

Table 2 sets out the methods of death. It shows that hanging was the most commonly used method (58%), followed by drowning (23%).

Suicide had been previously attempted by 37 individuals (65%), with 11 (19%) having made three or more attempts. All individuals who were reported to have had chronic pain (n=13) had had at least one previous suicide attempt. Table 3 shows that overdose was the most common previously attempted method of suicide, followed by attempted hanging. Fourteen individuals had previously attempted hanging, with 11 of these (79%) later dying by the same method.

Toxicology reports were available for 56 individuals (see Tables 4 and 5). Antidepressants and benzodiazepines were the most common medications identified. Of those individuals with a history of depression, only nine had antidepressants detectable in their toxicology. Only one of the five individuals who had been previously diagnosed with schizophrenia had antipsychotic agents in their toxicology. Thirty-four individuals had no alcohol in their blood at the time of death. Of those who did, 11% had levels above 200mg%.

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Conclusions

The study found that a history of previous attempted hanging was an important predictor of ‘completed suicide’ by hanging. The authors concluded that local policy for admission should reflect this risk.

The study also confirmed that recent discharge from inpatient service is a time of increased risk of completing suicide. Toxicology results also showed that less than one third of the individuals were taking their prescribed medication. The authors deemed this a high rate of non-compliance with treatment, and an important risk factor to consider when working with this group of patients.

High rates of adverse childhood adversity were reported in the case notes of individuals who died by probable suicide. The high levels of suicide attempts and/or deliberate self-harm show that a greater emphasis needs to be given to the national clinical programme for the management of self-harm.

While alcohol was not detected in 60% of individuals, it is still an indicator of increased risk.